People with limited literacy skills have worse health outcomes

People aged 70 years and older with limited literacy skills are one and one half to two times as likely to have poor health and poor health care access as people with adequate or higher reading ability, according to a study led by researchers at the San Francisco VA Medical Center and the University of California, San Francisco.

Elders with limited literacy, which the researchers define as a reading level lower than ninth grade, were one and a half times more likely than other study participants to report poor overall health and diabetes, and twice as likely to report depression. The study authors note that self-reported health has been found in other studies to correlate strongly with actual health.

The study of 2,512 community-dwelling elders between the ages of 70 and 79 revealed that one in four had limited literacy. In practical terms, these elders "may have trouble reading basic health information or pill bottle instructions," according to lead author Rebecca Sudore, MD, a staff physician at SFVAMC.

The study appears in the May 2006 issue of the Journal of the American Geriatric Society.

The researchers also found that people with a sixth-grade or lower reading level were twice as likely as the ninth-grade and above group to have poor access to health care, as measured by lacking a regular doctor or place of care, a flu shot within the previous year, or insurance to cover medication. Subjects with a seventh- to eighth-grade reading level also had less health care access compared to the ninth-grade group, but after accounting for other factors the differences were not statistically significant, according to Sudore.

The study authors emphasize that all results were adjusted for, and therefore independent of, patients' socioeconomic background and level of education.

"As a geriatrician, the results of this study break my heart," says Sudore, who is also an assistant adjunct professor of medicine at UCSF. "Elders already have the highest medication and disease burden. Adding limited literacy to the list of problems makes these elders particularly vulnerable to poor outcomes, as we found in our study."

The study analyzed data from in-person interviews of participants in the Health, Aging, and Body Composition Study conducted by the National Institute on Aging. Study subjects lived independently in the community in Memphis, Tenn., or Pittsburgh, Penn. The study excluded participants with dementia or poor physical functioning.

"Elders with limited literacy have a hard time reading their pill bottles, managing their diseases, filling out needed forms for their care, and being able to navigate through the health care system," notes Sudore. "Unfortunately, in this study, we found that the very group of elders who would benefit from having more access to health care actually had worse access. Since the elders in our study were fairly well-functioning, problems accessing care and managing disease are likely to be even worse for frailer elders."

The design of the study precluded an exploration of the reasons for the links between literacy, health, and health access, says Sudore, but she offers some possible explanations: "Patients with limited literacy may not understand instructions given to them by their clinicians, or grasp the importance of follow-up care. In addition, there may be elements of fear or intimidation or lack of trust in the health care establishment." Plus, she says, limited literacy may prevent elders from being able to properly fill out forms needed to obtain medical resources such as insurance and medications.

Sudore points out that among the study participants, literacy did not necessarily correlate with level of education, "which suggests that simply asking if someone graduated from high school will not tell you whether the person can understand his or her physician or read a prescription bottle. For our patients' sake, we need to be careful not to make assumptions about literacy skills. It is our responsibility, as clinicians, to talk to and to educate all of our patients in a way that they can understand."

Sudore says further research is needed to identify interventions that would prevent poor health outcomes in these "vulnerable elders." She points to multidisciplinary education programs that have been shown to be successful in geriatric and low-literacy populations. "Combining these two efforts may be what is needed," she speculates.

In the long run, predicts Sudore, successful interventions would save money for taxpayers: "People with limited literacy skills have worse health outcomes, poor access to health care - as our study showed - and are more likely to get their care in the emergency room and to be hospitalized, which has been shown to incur higher health care costs."